Velopharyngeal Muscle Morphology in Children With Unrepaired Submucous Cleft Palate: An Imaging Study.

OBJECTIVE: To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI) and noncleft controls with normal anatomy and normal speech. METHODS: Magnetic resonance imaging was used to evaluate the velopharyngeal mechanism in 20 children between 4 and 9 years of age; 5 with unrepaired SMCP and VPI. Quantitative and qualitative measures of the velum and levator veli palatini in participants with symptomatic SMCP were compared to noncleft controls with normal velopharyngeal anatomy and normal speech. RESULTS: Analysis of covariance revealed that children with symptomatic SMCP demonstrated increased velar genu angle (15.6°, P = .004), decreased α angle (13.2°, P = .37), and longer (5.1 mm, P = .32) and thinner (4 mm, P = .005) levator veli palatini muscles compared to noncleft controls. Qualitative comparisons revealed discontinuity of the levator muscle through the velar midline and absence of a musculus uvulae in children with symptomatic SMCP compared to noncleft controls. CONCLUSIONS: The levator veli palatini muscle is longer, thinner, and discontinuous through the velar midline, and the musculus uvulae is absent in children with SMCP and VPI compared to noncleft controls. The overall velar configuration in children with SMCP and VPI is disadvantageous for achieving adequate velopharyngeal closure necessary for nonnasal speech compared to noncleft controls. These findings add to the body of literature documenting levator muscle, musculus uvulae, and velar and craniometric parameters in children with SMCP.

Minimal scar repair of unilateral cleft lip.

BACKGROUND: Most conventional repairs for unilateral cleft lip are based on the notion that the two joined edges of skin should be the same length. To this end, they incorporate designs that include darts, cutbacks, rotation flaps, and other strategies to match the length of the two segments. As unequal skin edges are routinely joined surgically, it should be unnecessary to incorporate maneuvers in unilateral cleft lip repair to match the segment lengths. A repair that places the scar along the philtral ridge was developed. This eliminates scars that deviate from the aesthetic subunits. METHODS: Since 1982, a procedure has been used for unilateral cleft lip repair that incorporates the Kernahan functional muscle repair with a vertical skin closure, a white roll flap, and a dart at the nasal sill. The results of this lip repair, which does not intentionally match the segment lengths, are reviewed. Photographs of 10 consecutive patients who had their unilateral cleft lips repaired with this technique are presented for critical analysis. The mean age at operation was 15.4 weeks (range, 8 to 30 weeks). The mean postoperative period for the presented photographs was 66 months (range, 31 to 87 months). All of the patients healed without complications, and no revisions were performed. RESULTS: Preoperative and postoperative photographs of 10 consecutive patients demonstrate that normal lip length can be achieved without scars outside of the aesthetic subunits of the lip. CONCLUSION: The unilateral cleft lip deformity is repairable, with excellent results, without incorporating maneuvers to match the lengths of the opposing cut edges.

A long-term retrospective outcome assessment of facial growth, secondary surgical need, and maxillary lateral incisor status in a surgical-orthodontic protocol for complete clefts.

In 1965, the cleft palate team at Children's Memorial Hospital embarked on a new surgical-orthodontic protocol in the habilitation of newborn complete cleft lip and palate cases. It brought the orthodontic effort into focus at birth and in planned sequence to correspond with the surgical procedures of lip closure, maxillary alveolar stabilization by means of an autogenous graft of the authors' design, and complete palate closure, all within the first year of life. The purpose of this investigation is threefold: first, to review the authors' previous publications and assess growth, secondary surgical need, and lateral incisor status of teeth adjacent to the cleft in a series of patients who have all followed a precise, early surgical/orthodontic protocol; second, to compare these cases with other collaborative studies wherein this protocol was not used; and third, to report on an additional 82 cases with regard to secondary surgical need and the status of teeth adjacent to the cleft. Methods of assessment have included cephalometric radiography, periapical and occlusal dental radiography, computer-assisted tomography, plaster cast analysis, and intraoral and extraoral photography. The authors have demonstrated, along with other collaborative studies, that there is growth as good as other similar samples wherein there was no primary osteoplasty. In addition, the authors found their incidence of orthognathic surgery to be 18.29 percent; pharyngoplasty, 3.65 percent; and oronasal fistulas requiring surgical closure, 29.27 percent. In the case of unilateral complete clefts, 53.13 percent of those lateral incisors present adjacent to the cleft area were usable, and in bilateral cases, 57.77 percent were usable. The authors remain convinced after more than 35 years of following this successful protocol that early maxillary orthopedics and their technique of primary osteoplasty in planned sequence with lip and palate closure can produce a more favorable alignment of maxillary growth potential and, with comprehensive orthodontic treatment, can lead to teeth in a better overall occlusion than if these procedures had not been undertaken.